Download Patient History Errors

The 5 Most Common
Mistakes of the ICU
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of
academic medicine, and medical author. He
graduated from Ross University School of Medicine
and has completed his clinical clerkship training in
various teaching hospitals throughout New York,
including King’s County Hospital Center and
Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board
exams, and has served as a test prep tutor and instructor for Kaplan. He has developed
several medical courses and curricula for a variety of educational institutions. Dr. Jouria has
also served on multiple levels in the academic field including faculty member and
Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several
continuing education organizations covering multiple basic medical sciences. He has also
developed several continuing medical education courses covering various topics in clinical
medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson
Memorial Hospital’s Department of Surgery to develop an e-module training series for
trauma patient management. Dr. Jouria is currently authoring an academic textbook on
Human Anatomy & Physiology.
Abstract
By its name, Intensive Care indicates the utmost level of attention to the
critically ill patient. ICU patients are typically monitored by numerous
machines, as well as by many physicians, nurses, therapists, and other
medical professionals to ensure their wellbeing. But even with such a
thorough level of care — and sometimes because of it — mistakes can be
made in the ICU. This course examines the five most common mistakes of
the ICU and offers strategies for preventing these mistakes. It also identifies
the responsibilities of medical and nursing professionals should a mistake
occur.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Nurses caring for patients in the ICU administer more medications and
manage more treatments than in other area of healthcare. An awareness of
common mistakes in the ICU is needed, including recommended strategies
to improve patient care processes and to prevent mistakes from occurring.
Course Purpose
To provide nursing professionals with knowledge of common ICU mistakes,
and steps to address mistakes when they happen and to prevent recurrence.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 5/2/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Which of the following correctly lists symptoms of a pulmonary
embolism
a. A sudden drop in blood pressure
b. A sudden rise in blood pressure
c. Tachycardia, dyspnea, coughing
d. Fever, lumbar back pain and shortness of breath
2. You have a number of patients in the ICU. Which of the following
conditions would likely put them at greatest risk of aspergillosis?
a. Thrombocytopenia
b. Mechanical ventilation
c. Hypothyroidism
d. Sedation with a lowered respiratory rate
3. Which of the following represents the greatest risk for
pneumonia?
a. A history of abdominal surgery
b. Endotracheal intubation with mechanical ventilation
c. Age under 65
d. Male gender
4. Which of the following symptoms may be confused with a heart
attack?
a. Aspergillosis
b. Pulmonary embolism
c. Ectopic pregnancy
d. Sepsis
5. According to the Joint Commission, sentinel events:
a. Signal the need for immediate investigation and response
b. Require mandatory reporting
c. Are always investigated at every hospital
d. Are all unexpected occurrence involving death or serious physical
or psychological injury
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Introduction
In 1999, the Institute of Medicine published a landmark report highlighting
that preventable medical errors account for not less than 44,000 annual
deaths in the United States, but this number may be as high as 98,000.1 It
is likely the number may be higher because of the low rate of voluntary
reporting. Deaths from preventable medical errors were greater than the
number of deaths from automobile wrecks, breast cancer, and AIDS, even
with the lower estimate of 44,000. The report also made clear that the
highest error rates with the most serious consequences were most likely to
occur in intensive care units, operating rooms, and emergency departments.
The total costs that result from preventable medical errors are estimated to
be between $17 billion and $29 billion per year in hospitals nationwide.1
Patients pay the price of longer hospital stays and greater physical
discomfort and psychological risk. Health care professionals “pay” because of
frustration, guilt and loss of morale. Society in general also “pays” because
of lost productivity, loss of working hours, loss of school attendance and
overall loss of health and wellness. The report produced an inclusive strategy
to reduce the frequency of preventable medical errors.
The types of medical errors addressed in this report included adverse drug
events (including wrong medicine, wrong dose, wrong patient or other
error), improper or inappropriate transfusions, surgical injuries and wrongsite surgery, suicides, restraint-related injuries or deaths, falls, burns,
pressure ulcers, and mistaken patient identities.
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Types of Errors cited in the IOM report, To Err is Human1
Diagnostic
 Error or delay in diagnosis
 Failure to employ indicated tests
 Use of outmoded tests or therapy
 Failure to act on results of monitoring or testing
Treatment




Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an abnormal
test
 Inappropriate (not indicated) care
Preventive






Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment
Other
Failure of communication
Equipment failure
Other system failure
Mistakes in the ICU are too common. Nurses are ideally positioned to
prevent errors and intervene when they see “errors in the making.” The
most common mistakes made in the ICU were preventable ones and they
will be reviewed. Also, communication and collaboration issues will be
discussed along with various strategies that may be used to prevent ICU
errors.
Patient History Errors
Recent studies indicate “access to clinical history can both enhance
diagnostic accuracy and increase diagnostic error.”2 Unexpected physical
findings can cause a change in the primary diagnosis or may bias the
clinician to a completely different diagnosis.3 One of the elements that can
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bias the clinician and health care professionals is the presence or lack of preexisting conditions.
Pre-existing Conditions
Bias is an important consideration during evaluation of patient pre-existing
conditions, and can be of a number of types:

Confirmation bias—where evidence is actively sought for the
presence of a condition that confirms the hypothesis

Anchoring bias—where the eventual diagnosis is similar to the
original diagnosis

Premature diagnostic closure—where the diagnosis is deemed
final without adequate examination of the alternatives. Gender
bias may often be of this nature.
Discordant physical findings generally result in a rejection of the original
diagnosis but do not necessarily increase the accuracy of the final diagnosis.2
For example, COPD (chronic obstructive pulmonary disease) has historically
been associated with men more than women. COPD may be underdiagnosed in women, just as heart attacks have been, because of this
gender bias. Both smoking and non-smoking associated co-morbidities are
more common in men and women with COPD when compared to men and
women without COPD;4 however, tends to be diagnosed less frequently in
women than in men and this under-recognition can lead to less testing and
less treatment for pneumonia and other respiratory disorders.
In the ICU, under-recognition of COPD can delay treatment significantly and
potentially with severe adverse consequences. In view of the fact that a
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significant number of complications in the ICU are of a pulmonary nature,
this type of information may be critical. If there is also an incomplete patient
history — either based on the clinical condition of the individual on
admission or because of an inadequate intake — a significant co-morbid
impact on the care and treatment of the patient may very well be missed.
A recent study using autopsy results to determine the rates of diagnostic
errors found that at least 28% of autopsies reported at least one
misdiagnosis. A fraction of these may have been based on inaccurate patient
histories. The authors did conclude that infections and vascular events were
a frequent source of errors and that an effective patient history may be
considered a way to avoid.5
Patient history information can come from the patient themselves, their
family and caregivers or from existing medical records. Electronic Medical
Records (EMRs) are becoming more universally available and should, in
theory, include a transmittable and comprehensive record. Examples of comorbid or pre-existing conditions that may impact on critical care include:
 Pneumonia in the elderly associated with:6
o Cardiovascular disease
o COPD
o Diabetes
 Note that the elderly must be particularly monitored for
aspiration pneumonias
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 Advanced chronic kidney disease (CKD) and End Stage Renal Disease
(ESRD) and:7
o Sepsis
o Acute lung injury
o Post-operative status
 These patients must be closely monitored for water and
electrolyte balance, coagulopathies and antibiotic resistant
infections. In addition, many of these patients have
additional complicating co-morbidities including
cardiovascular diseases, diabetes, impaired immune
systems and impaired wound healing.
Every effort must be made to determine as complete a medical history as
possible from the patient, and the patient’s family, primary care provider or
from hospital records. If any co-morbidity is suspected, the appropriate
medical staff should be advised so that staff may be as well informed as
possible during continued treatment.
Allergies or Sensitivities to Medications, Substances, Foods
Patients in the ICU may not always be able to communicate their medication
allergies to ICU staff, i.e., penicillin, aspirin, sulfa drugs, nonsteroidal antiinflammatory drugs (NSAIDs), phenytoin or other anticonvulsants, insulin, or
iodinated contrast dyes. Patients may not be able to communicate their
sensitivities to foods (i.e., eggs, milk, fish, gluten) or other substances
commonly used in a hospital setting such as latex, parabens or disinfectants.
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In theory, any medication can result in an allergic response.8-11 If
computerized medical records are available for the patient, the nursing staff
should make every effort to become alerted to potential allergic responses.
If the patient is able to communicate, he or she should be asked early if he
or she is aware of any allergies or sensitivities to various chemical agents.
Family members should also be queried if possible.
Allergic reactions or adverse reactions are best treated early. Every patient
should be observed after receiving medication for any adverse reactions.
This is most important the first time a patient receives a specific medication,
although it must be emphasized that adverse reactions can occur at any
point during the course of treatment.8-10
Diagnostic Errors
Research suggests that diagnostic errors result in very significant patient
harm and mortality. This is an area that has been difficult to study and it is
unknown exactly what might be the true significance of the harm.12-14
Clearly, every patient deserves an accurate diagnosis, but just as clearly,
this is not always possible. However, every health care professional needs to
be aware of possible errors and to always remain open to the possibility that
a diagnostic error has occurred or that a new condition has developed that
may necessitate a change in treatment approaches.
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Heart Attacks
Overview
Coronary artery disease (CAD) is a leading cause of death. In the ICU, the
major concerns are the acute coronary syndromes including unstable angina,
both STEMI and non-STEMI (NSTEMI) myocardial infarcts (MI) and sudden
cardiac death. Coronary artery disease is in general due to depositions of
atheromas (deposits of degenerative accumulations of lipid-containing
plaques located in the subintimal layer of an artery). It may also be the
result of coronary spasm (with or without atheromas), though this is less
common. Other rare causes of CAD include embolism in a coronary artery,
aortic or arterial dissection, an aneurysm and vasculitis.
Risk factors for CAD include:
Lab values of 
High blood levels of low-density lipoprotein (LDL) cholesterol and
lipoprotein

Low blood levels of high-density lipoprotein (HDL) cholesterol

Hyperhomocysteinemia

High levels of apolipoprotein B (apo B) especially if there are high
levels in the presence of normal levels of total cholesterol or LDL.
Type 2 diabetes mellitus 
Smoking

Obesity

Sedentary life choices

Genetic factors
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
Systemic disorders
o Hypertension
o Hypothyroidism
Acute Coronary Syndromes (ACS)
Acute Coronary Syndromes can be divided into a number of classes:

Unstable angina- where resting angina lasts longer than 20 minutes,
new angina symptoms are at least Class 3 or an increasing frequency,
severity, length of angina symptoms that increase by at least one or
more classes to Class 3.

Transient EKG changes may occur (ST-elevation/depression or T-wave
inversion)

Creatine Kinase (CK) is usually normal, but high-sensitivity troponin
tests (hs-cTn), may be slightly increased.
Table 1: Canadian Cardiovascular Society Classification System of Angina. [15]
Class
1
Sample activities causing angina symptoms
Strenuous exertion. Prolonged.
New or untried physical activity
2
Rapid walking or climbing stairs (especially after eating)
Cold
Wind
Emotional stress
3
Walking at usual pace, on level ground. Climbing stairs.
4
Any/All physical activity. May occur while at rest.
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
Non-ST-elevation MI (NSTEMI)

EKG will not show ST-elevation or Q-waves. ST-depression or T-wave
inversion may be present.

Creatine Kinase (CK) and Troponin I/T will be elevated.

ST-elevation MI (STEMI)

EKG will show ST-elevation and possibly Q-waves. Possible appearance
of a LBB Block (Left bundle branch block)

Creatine Kinase (CK) and Troponin I/T will be elevated.
Signs and Symptoms
The symptoms of ACS may be difficult to distinguish, particularly in an ICU
setting. Constant monitoring and constant awareness is the best approach.
I
Severe angina
New onset or increasing
II
III
Clinical classification that may be
added to the Severity Rating:
No anginal symptoms at rest
A: Angina that is secondary to a non-
Anginal symptoms at rest
cardiac condition that exacerbates
within last 30 days, but not
myocardial ischemia.
during last 48 hrs.
B: Angina without a non-cardiac
Anginal symptoms at rest
condition. In Class IIIB, troponin status
within last 48 hrs.
is used for prognostic purposes.
C: Develops within 2 weeks post MI.

Unstable Angina:
o Discomfort or pain is more intense and is caused by little
exertion. May occur at rest (angina decubitus) or may be
progressive (crescendo angina). Anginal discomfort may radiate:

To the left shoulder and inside of the left arm up to the
fingers
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
Straight through to the back

Into the jaws, teeth and throat

The inside of the right arm (more often in women)

Upper abdomen

Atypical angina may be reported as indigestion,
abdominal/GI distress

Dyspnea

Auscultation:
 More distant heart sounds
 Paradoxical 2nd heart sound
 May detect 3rd/4th heart sounds
 Mid- or late systolic apical murmur may occur



May be an increase in heart rate (HR), blood pressure (BP)
Apical impulse may become more diffuse
NSTEMI and STEMI:
o Pain and/or discomfort may be prodromal with

Unstable or crescendo angina, shortness of breath, fatigue.
o Substernal pain. May be described as “pressure” or aching.
o May radiate to:

All or some/one: Back, jaw, left arm, right arm, shoulders

May be accompanied by:
 Water brash
 Dyspnea
 Diaphoresis
 Nausea/Vomiting

Not generally relieved by rest

20% of MIs (Myocardial Infarcts) are silent
 Atypical symptoms more common in women
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 Elderly more commonly report dyspnea than chest
pain(s)

Physical Signs and Symptoms (SSx):
 Skin: pale, cool, diaphoretic
 Cyanosis (peripheral or central) may be present
 An irregular pulse or hypertension may be present

Auscultation:
 Distant heart sounds with nearly universal 4th heart
sound present
 Friction rub may be present—if so, rule out
pericarditis. Friction rubs are common post-STEMI.
 Soft, systolic, blowing apical murmur may be present
 In Right Ventricular infarcts, distended jugular vein
(+/-Kussmaul sign)
Prevention of Misdiagnosis
Differential Diagnosis:

Pneumonia

Pulmonary embolism

Pericarditis

Esophageal spasm

Acute aortic dissection

Musculoskeletal pain (costochondritis, rib fracture, costochondral
dislocation)

Kidney stones

GI disorders
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Intensive care unit patients must be continuously monitored utilizing both
devices and direct physical assessment. The nursing staff must be aware of
any diagnostic changes in EKGs as well as monitor their patients for any
potential symptoms. ICU patients may be scored using APACHE IV scoring
for prognosis. (APACHE = Acute Physiologic and Chronic Health Evaluation)17
The Agency for Healthcare Research and Quality (AHRQ) has published
guidelines for the diagnosis and treatment of ACS. ICU patients are
considered high risk and early therapy is recommended. Early therapy may
include:
 Aspirin or P2Y12 inhibitor (i.e., clopidogrel)
 O2 saturations should be at >90%
 For STEMI patients, Percutaneous Coronary Intervention (PCI) should be
done within 90 minutes. Otherwise, fibrinolysis may be a secondary
choice.
 For unstable angina and NSTEMI, angiography to determine if PCI or
Coronary artery bypass grafting (CABG) may be required.
 Post ACS, aspirin, β-blockers, ACE inhibitors, and statins may be ordered
unless contraindicated.
Pulmonary Embolism (PE)
Overview
Pulmonary embolism (PE) is the blockage of one or more pulmonary arteries
by thrombi (clots) that originate most often in the large veins of the lower
extremities or the pelvis. Risk factors include:
 Atrial fibrillation
 Heart failure
 Cancer
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 Patients with a history of smoking
 History of exogenous estrogens and progestins
 Pelvic trauma
 Impaired venous return
 Conditions that cause endothelial injury or dysfunction
 Underlying hypercoagulable states
 Immobilization
 Obesity
 Sickle cell anemia
 Post-surgical
 Age over 60 years
ICU patients may also be at risk for non-thrombotic emboli including those
outlined below:
 Air emboli:
These may result from surgery, blunt trauma, defective venous
catheters, and errors that may occur during either the insertion or
removal of central venous catheters.
 Fat emboli:
Fat emboli may result from fractures, orthopedic procedures,
microvascular occlusion, and necrosis of bone marrow in patients with
sickle cell crisis. Rarely, fat emboli result from toxic modification of
native or parenteral serum lipids.
 Septic emboli:
These may result from IV drug use, right-sided infective endocarditis,
and septic thrombophlebitis.
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 Tumor emboli:
These may result from the access of neoplastic cells into the pulmonary
arterial system.
Signs and Symptoms
Smaller pulmonary embolisms are often self-limiting, though they may not
be in critically ill ICU patients. Symptoms, if they appear, may be vague and
non-specific. The most common symptoms of PE are tachycardia and
tachypnea. Large PE may also cause acute dyspnea and/or pleuritic pain.
Cough and hemoptysis may also be noted. This may be of particular concern
in those ICU patients who cannot sit up or who are sedated. In elderly
patients, the first sign of PE is often an altered mental status. Fever can
occur as well. Less commonly, patients have hypotension. Labs may indicate
increased D-Dimer, but this is not diagnostic.
Auscultation may reveal:
 A loud 2nd heart sound (S2) and/or a loud pulmonic component (P2)
 Crackles or wheezing
 If right ventricular failure is present:
o Distended internal jugular veins
o A right ventricular heave may be evident
o Right ventricular gallop (S3 and S4), with or without tricuspid
regurgitation, may be audible
Chest X-rays may reveal atelectasis, focal infiltrates, an elevated
hemidiaphragm, or a pleural effusion. Findings considered classic but non-
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specific include Westermark's sign (focal loss of vascular markings),
Hampton's hump (the presence of a peripheral wedge-shaped density), or
Palla's sign (enlargement of the right descending pulmonary artery). Other
imaging techniques may be useful. Ventilation or perfusion scans (V/Q
scans) can give a probability measurement of PE and ultrasonography can
detect clots. Computerized tomographic (CT angiography) is only useful if
the patient can hold their breath for more than a few seconds.
Pulse oximetry may reveal hypoxemia and arterial blood gas sampling may
show an increased alveolar to arterial oxygen (A-a) gradient. EKGs are
generally non-specific.
Prevention of Misdiagnosis
Differential Diagnosis:
Pulmonary embolisms should be included in the differential diagnosis when
non-specific symptoms such as dyspnea, pleuritic chest pain, fever,
hemoptysis, cough and altered mental status are noted in an ICU patient.
Pulmonary embolisms should be considered also if these symptoms appear
in patients with cardiac ischemia, heart failure, COPD, pneumothorax,
pneumonia, sepsis, patients with sickle cell anemia and acute chest
syndrome. Finally, PE should be considered in patients with acute anxiety
with hyperventilation.
Observation, monitoring and direct assessment are critical. Invasive tests
such as pulmonary angiography may be necessary in an acutely ill patient.
An estimated 10% of patients with PE die within the first hour. Only about
30% of those that survive the first critical hour are diagnosed and their best
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chance of survival resides in early, prompt and accurate diagnosis.18-21
Observation and close attention are the best defenses a healthcare
professional has for any missed or late diagnosis.
Pneumonia
Overview
Pneumonia is an inflammation of the lungs caused by infection by a
pathogen, though often, the specific pathogen cannot be determined.
Pneumonia may be:

Community-acquired

Hospital-acquired
o Ventilator-acquired pneumonia (VAP)
o Postoperative

Nursing home–acquired

Opportunistic in immunocompromised individuals
Hospital-acquired pneumonia (HAP) or nosocomial pneumonia is the most
common fatal infection in the hospital setting.22,23 By definition, HAP
develops at least 48 hours after admission. Gram-negative bacilli and S.
aureus are the most common in adult patients over 30. In ventilated
patients, decreased oxygenation and increased tracheal secretions may
herald the infection. Included under the umbrella term HAP are VAP,
postoperative pneumonia, and healthcare associated pneumonia (HCAP),
where patients in chronic care facilities, dialysis centers, and infusion centers
may acquire pneumonia in the healthcare setting.22,24-28
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The greatest risk factor for HAP is endotracheal intubation with mechanical
ventilation.25 Other risk factors include:

History of antibiotic treatment

High gastric pH

Comorbidities:
o Cardiac
o Pulmonary
o Hepatic
o Renal insufficiency

For postoperative pneumonia, risk factors include:
o Age over 70
o Abdominal or thoracic surgery
o Bedridden patients
Pathogens vary, but the most common in the ICU are Pseudomonas
aeruginosa, Legionella, Mycoplasma pneumoniae, C. pneumonia, H.
influenzae, Moraxella catarrhalis, Enterobacter sp., Klebsiella pneumoniae,
Escherichia coli, Serratia marcescens, Proteus sp., and Acinetobacter sp.,
and methicillin-sensitive or resistant S. aureus. A growing percentage of
these pathogens are multi-drug resistant (MDR).29-34 Gram positive
pathogens are increasing in vancomycin-resistance and tolerance while gram
negative pathogens are increasing resistance via mechanisms that include
mutations in efflux pumps or in enzymatic pathways.31, 34
Signs and Symptoms

Malaise

Cough
o Usually productive in adults and older children
o Usually dry in infants, younger children and the elderly
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
Dyspnea
o Usually mild

Chest pain
o Pleuritic
o Commonly adjacent to the infected area

Nonspecific irritability and restlessness in infants

Confusion, changes in alertness in the elderly. They may appear
obtunded, i.e., dulled, as well. Dementia may also be considered, but
it is important to note that while dementia in an ICU patient is
problematic, medically, it is not necessarily an emergency while
pneumonia is an emergency.

Signs:
o Fever (often absent in the elderly)
o Tachypnea
o Tachycardia
o Infants:


Nasal flaring

Use of accessory muscles

Cyanosis
Auscultation/Percussion:
o Crackles, bronchial breath sounds,
o Egophony
o Dullness to percussion
Prevention of Misdiagnosis
Diagnosis is generally by chest X-ray, the clinical findings and occasionally
by using bronchoscopy and sputum or blood cultures. Cultures do not always
reveal the specific pathogen and may take too long to be clinically useful.
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Cultures should still be obtained because they may be useful if the pathogen
is drug-resistant. In this case, drug sensitivity studies may be necessary.
Diagnosis may be confused by existing co-morbidities and because similar
symptoms are seen in atelectasis, pulmonary embolism, pulmonary edema
or acute respiratory distress syndrome (ARDS).
In general, pulmonary emboli are more likely in patients with non-productive
coughs, with fewer overall symptoms and who have a number of risk factors
for thromboembolic events. Higher fevers, higher white blood cell counts
with purulent secretions and low O2 saturation levels place the patient at a
higher clinical likelihood of pneumonia. Treatment consists primarily of
empirically chosen antibiotics. The decision to use a specific antibiotic or
antibiotic combination is based on a number of factors including:

Local sensitivity/etiology patterns

Specific patient risk factors
Pseudomonas is ubiquitous in the hospital environment. The greatest single
method available to reduce Pseudomonas infections includes hand washing
and aseptic techniques by health care professionals. Risk factors for
Pseudomonas include:

Neutropenia

Previous or current treatment with antibiotics

History of cytotoxic or corticosteroid treatment

Hospital acquisition of infection

Detection in the intensive care unit

Male gender
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Intensive care unit patients with few Pseudomonas risk factors may be
treated with IV β-lactams (i.e., cefotaxime, ceftriaxone) plus IV
fluoroquinolone or azithromycin. ICU patients with Pseudomonas risk factors
may be treated with IV antipseudomonal β-lactams (i.e., cefepime,
meropenem, piperacillin/tazobactam), or aztreonam (if the patient is allergic
or non-tolerant to β-lactams) plus either IV ciprofloxacin or levofloxacin. An
aminoglycoside may be added as well.
Aspergillosis
Overview
Aspergillus, or more specifically Invasive Pulmonary Aspergillosis (IPA) is a
common fungus (mold) found in soil, compost heaps, insulating materials,
operating rooms (often in the air conditioning or heating ducts) plants and in
decaying matter. The most common species are Aspergillus fumigatus, A.
flavus, A. terreus, A. nidulans, and A. niger. It is an opportunistic infection
with spores affecting the sinuses and blood vessels of the lungs. Spores
propagate causing a hemorrhagic necrosis and potential infarcts. Aspergillus
fumigatus is the most common cause of pulmonary disease while Aspergillus
flavus is more commonly associated with infections of the sinuses or with
otitis.35-37
Risk factors for aspergillosis include:

Neutropenia

Long-term, high-dose corticosteroid or immunosuppressive therapy

Organ transplantation (especially after bone marrow transplantation)

Hematological malignancies
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
Hereditary disorders of neutrophil function such as neutropenia,
chronic granulomatous disease

AIDS or other immunocompromised conditions
An aspergilloma is a fungus ball that sometimes forms in the lungs. Masses
of fungal hyphae, inflammatory cells, and fibrin exudate form the core of the
ball and it is encapsulated within fibrous tissue.38-40 Allergic Broncho
pulmonary aspergillosis is an allergic reaction to the fungus and may occur
in ICU patients as well.36,37,41-43
Signs and Symptoms
The most common symptoms of pulmonary aspergillosis are a cough, often
accompanied by hemoptysis and fever, and shortness of breath. Symptoms
of a sinus infection with Aspergillus spp., include fever, headache and sinus
pain. Skin lesions can turn black. Positive sputum cultures may be due to
environmental contamination because Aspergillus spp., are ubiquitous in the
environment. On the other hand, sputum cultures from patients with
aspergillosis may be negative because the fungus has become encysted.44
Samples taken via bronchoscopy are generally positive, but because cultures
take time, ICU patients are often treated before the results of the culture are
known.
Chest X-rays classically show a “halo” or “air crescent” around lesions.
These are thought to represent cavitation within the lesion; however, these
are not always seen.
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Treatment consists of the anti-fungal agents, voriconazole or amphotericin
B. Surgery may be performed for visualized aspergillomas. The
immunocompromised patient is at risk for recurrence until and unless the
immunocompromised condition is reversed. The Centers for Disease Control
and Prevention considers aspergillosis rare; but, because aspergillosis is not
a reportable condition, its actual frequency can only be estimated.
Population data suggest it occurs in 1 to 2 cases per 100,000 patients every
year.
Prevention of Misdiagnosis
In a recent study, in-hospital mortality for adult ICU patients with diagnosed
invasive aspergillosis (AI) was 46%.44 Each 24 hour lag before diagnosis
represented 1.28 days longer in the ICU. Survival outcome is influenced by
early intervention. Patients on mechanical ventilation, with compromised
immune or respiratory systems or with any of the risk factors for
opportunistic fungal infections must be closely monitored and observed for
potential signs and symptoms and treated with anti-fungal agents as soon as
clinical suspicion is obtained.45
Abdominal Bleeding and Acute Abdomen
Overview
Acute abdominal pain is nearly always reflective of significant intraabdominal disease. It must be dealt with quickly particularly in the very
young, the very old and the immunocompromised patient.
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Signs and Symptoms
Abdominal pain may be described as:

Visceral pain, using terms such as distention, bloating and cramping.
Visceral pain is not tearing or stabbing pain. Visceral pain is often
vague, nauseating, dull and non-localized. (Visceral pain is termed
visceral because it stems from the abdominal viscera, or internal
abdominal organs).

Somatic pain is described using terms such as stabbing, sharp or
tearing pain. The pain tends to be well localized and often results from
infections, toxic substances or a generalized inflammatory process.

Referred pain may be described as dull or aching.
The location of pain can often give diagnostic clues regarding causes. Extraabdominal causes of abdominal pain must be considered as well. These
include:

Metabolic causes o Alcoholic or diabetic ketoacidosis
o Adrenal insufficiency
o Hypercalcemia
o Porphyria
o Sickle cell disease

Genitourinary o Testicular torsion
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
Thoracic o MI
o Pneumonia
o Pulmonary embolism
o Radiculitis

Other o Opioid withdrawal
o Sepsis
The descriptors listed in the table below can assist with a diagnosis, if the
patient is communicating.
TYPES OF PAIN
POSSIBLE CAUSES
Sharp constricting pain coming in
waves that may be described as
“takes my breath away”
Consider renal or biliary colic
Dull pain with vomiting (may come in
waves)
Consider intestinal obstruction
Sharp (colick) pain. Becomes steady
and unremitting
Consider appendicitis, intestinal
obstruction, mesenteric ischemia
Sharp, constant pain, made worse by
any movement
Consider dissecting aneurysm
Tearing pain
Consider appendicitis, diverticulitis,
pyelonephritis
Dull ache
Consider peritonitis
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Prevention of Misdiagnosis
A physical examination is essential and should include general inspection,
auscultation, palpation and percussion, in that order.
Inspection obviously should focus on the
abdomen, but it is important to get an overall
Red Flags for Abdominal
Pain
view of the patient as well. Are they anxious?
Are they diaphoretic? Are they conscious and
able to respond? Is there a reason to suspect
 Severe pain
 Signs of shock
o
Tachycardia
abdominal bleeding? Are they post-surgery or
o
Hypotension
post-trauma patients? Are they communicating
o
Diaphoresis
pain in any way?
o
Confusion
 Signs of peritonitis
 Abdominal distention
Rectal and pelvic examinations may be essential as well, depending on the
specifics of the patient’s condition. A full examination, as described below,
can rule in and rule out various conditions and can include blood tests
(CBCs, Comprehensive Metabolic panels, urinalysis — i.e., testing for
pregnancy in women), though they are seldom of diagnostic value. High
values of serum lipase, however, can be strongly suggestive of acute
pancreatitis. Increased numbers of neutrophils can indicate an active
infection and lab values can indicate ketoacidosis. A decreased hematocrit
can indicate internal bleeding.46

Inspection:
o Distention around surgical scars along with high-pitched
peristalsis and/or borborygmi (rumbling bowel sounds) suggests
a bowel obstruction.
o Location of the pain can narrow down the diagnostic possibilities
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o Discoloration (ecchymoses/hematomas) around the umbilicus
(Cullen sign) or the costovertebral angles (Grey Turner sign) can
suggest pancreatitis.
o Back pain along with signs of shock may indicate a ruptured
aortic aneurysm. This suspicion is stronger with a mass that is
tender and pulsating.
o Is there evidence of jaundice?

Auscultation:
o Tympanic responses to percussion (along with high-pitched
peristalsis and/or borborygmi) suggest a bowel obstruction.
o Abdominal bruits are associated with vascular pathology, usually
arterial.
o If unable to determine liver size, the “scratch test” may be
useful: Hold the diaphragm of the stethoscope over the liver
(approximately over the assumed “center”), and listen for
change in the quality of sound as the opposite hand gently
scratches the abdomen. Move in a semicircle around the
stethoscope.

Palpation:
o Palpation should begin gently, away from the area of most
severe pain. Note any:

Guarding — an involuntary muscle contraction — this is
generally slower and lasts longer than a “flinch”

Rebound — a “flinch” when the examiner removes his or
her hand.

Rigidity
o Guarding, rebound and rigidity can all suggest peritonitis
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o Check for ascites
o Check for Murphy’s sign

Murphy’s sign is a test for gallbladder disease where the
patient is asked to inhale while the examiner's fingers are
hooked under the liver border (at the bottom of the rib
cage). The intake of breath causes the gallbladder to drop
onto the fingers. If the gallbladder is inflamed, this will be
painful. Deep breaths may also be very limited.

Confirmatory signs of appendicitis. (Note that the absence of these
signs does not exclude appendicitis).
o Check for psoas sign.

The psoas test is performed by passively extending the
right thigh of a patient lying on their left side with the
opposite knee extended.
o Check for Obturator sign

Pain on internal rotation of right thigh. (This may indicate
a pelvic appendix.)
o Check for Rovsing's sign

Pain in right lower quadrant with palpation of left lower
quadrant
o Check for Dunphy’s sign

Pain is increased when the patient coughs
Abdominal Imaging
If possible, imaging should be done. Chest X-rays – lateral recumbent
abdominal and anteroposterior - may reveal a perforation or obstruction.
Ultrasounds may be performed for suspected biliary tract disease.
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Ultrasounds can also detect ruptured aneurysms but are not reliable. If
kidney stones are suspected, non-contrast CTs can be taken. Computerized
tomography scans with oral contrast is diagnostic in 95% of patients, but
may not be possible with some ICU patients.46
Abdominal Bleeding
A recent study found that bedside diagnostic laparoscopy is a minimally
invasive and safe procedure for hemodynamically unstable patients in the
ICU. Bedside laparoscopy had a high diagnostic accuracy.47 If abdominal
bleeding is suspected, further immediate investigation is essential.46 In this
case, ultrasonography or CT imaging is strongly recommended. Surgical
intervention may be required immediately. Serum lactate or base deficits
(and/or serum HCO3-) should be assessed and used as they are sensitive
tests to evaluate the extent of bleeding.48-54 Additionally, if abdominal
bleeding is suspected, coagulation parameters should be monitored. These
include the combined measurement of prothrombin time (PT), activated
partial thromboplastin time (APTT), fibrinogen and platelets. However, time
may be of the essence and thromboelastometry and viscoelastic testing is
much more rapid.46,55,56
The “STOP the Bleeding Campaign"46 was an international initiative begun in
2013 with the goal of reducing morbidity and mortality associated with
bleeding following traumatic injury. STOP stands for:

Search for patients at risk

Treat bleeding and coagulation disorders immediately

Observe patient’s response(s)

Prevent secondary bleeds and development of coagulation disorders
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These guidelines were intended for trauma patients, but the general
approaches are applicable for all acute care patients. Nursing staff should
always be aware and searching for patients showing signs of increased
distress, notify medical staff and treat the patient accordingly, always
observing the response of the patient with an eye for prevention of further
problems.
Medication Prescription Errors
Overview
Medication errors are a significant part of health care costs as are adverse
drug events (ADEs), sometimes known as adverse drug reactions (ADRs).
Adverse drug events can range from relatively mild with uncomfortable
symptoms to disability and can be fatal. Up to an estimated 180,000 to
200,000 people die annually from preventable medication errors and
estimated millions experience ADE from medication errors.57-60 The most
recent nursing home survey reported that though medication errors are
prevalent, the number of ADEs actually reported was too low to adequately
analyze.61
One recent study estimated that errors in injectable medications increased
costs by $2.7 billion to $5.1 billion annually with an average cost per
hospital of $600, 000.62 The most common error for injectable medications
was insulin.62 Another study that measured immediate costs in addition to
the cost of “lost human potential and contributions” estimated that nearly a
trillion dollars is lost annually to the economy from medication errors.57
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Many of these medication errors are preventable and some reforms have
been addressed in legislation via the ACA, including focusing on preventable
re-admissions and iatrogenic conditions.63 A recent survey of more than 800
nurses, hospital administrators and physicians indicated that during the most
recent recession (with many hospitals and healthcare facilities cutting back
on personnel) medication errors or medication safety was the most
important problem facing hospitals and ICUs. The most cited problems
concerning medication safety were:57

42% felt that the elimination or reduction in time spent by key safety
personnel such as medication safety officers was a grave concern

33% noted that there was less clinical pharmacist involvement in
patient care units specifically.

Others noted a reduction in time allotted for nursing education coupled
with the greater use of part-time or registry nurses who may not be
familiar with the facility’s specific approaches to medication safety and
have not been trained by that facility regarding medication safety.
A recent landmark paper looked at various programs for improving quality
care, including reducing medication errors.57 The approaches this paper
looked at included:

Incentives and Penalties for quality care o The study cites that the Center for Medicare Services (CMS) will
no longer reimburse providers and hospitals for preventable
hospital readmissions. Initial focus is on MIs, heart failure and
pneumonia. Those hospitals may lose the ability to admit
Medicare patients. In addition, the CMS will publicize the best
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and the worst performing hospitals, with the hope that “public
notification could damage institutional reputations and be the
dominant force in shifting market position or leadership.”57
o By the year 2017 and based on quality performance measures,
up to 6% of diagnosis-related group payments will be in
jeopardy.
o Initially, quality reporting by physicians will be voluntary,
accompanied by bonuses, but by 2015, individual performance
reports will be mandatory and published on the CMS site.
Hospitals and nursing homes are now required to report to the
CMS.
o Physicians appear to be responding, particularly with their
compensation linked to performance.57,64,65

Innovation o In 2011, the Center for Medicare and Medicaid Innovation was
instituted with the express goal of testing innovative payment
and service delivery models. Twenty models are currently in the
law, but the legislation allows for a greater diversity of
innovative models.

Individual examples of improving quality of health care included57 o Decreasing the numbers of induced labors and unplanned
cesarean sections
o Immediate and aggressive treatment of acute respiratory
distress syndrome along with the improvement in the use and
operation of mechanical ventilators. With this approach, “…
patient survival increased from 9.5 percent to 44 percent.
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Physician time involved in care dropped in half and the total cost
of care dropped by 25 percent.”57
o Developing a culture of patient safety by instituting policies
where “errors are quickly identified, disclosed to patients or their
families, root-cause analyses are conducted, and the results are
shared with those who have been affected, and financial
settlements are made when appropriate to help the patients and
their families begin the healing process. These analyses are also
used to change systems and the way procedures are done in
order to prevent recurrences.”57
Types of Drug Errors
Drug errors can involve a number of factors that may stand along or work in
combination with each other. Some of the most common errors include:

An incorrect choice of a drug or a prescription:
o Wrong dose
o Wrong frequency
o Wrong duration

Pharmacist reading errors

Caregiver reading errors

Incorrect or clearly misunderstood patient instructions

Incorrect administration by a clinician, caregiver, or patient

Faulty storage of a drug that alters potency
o By the pharmacist
o By the patient
o Use of an outdated drug

Inaccurate communication, transmission or recording of prescription
information
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o Lack of communication between different providers
o Lack of communication between patient and provider
Approaches to Minimize Errors
Electronic Medical Records (EMRs) should, at least in theory, overcome a
number of these concerns, particularly as many are directly related to poor
or unclear handwritten orders or telephonic orders. The EMRs should also
avoid confusion with certain traditional abbreviations such as “qd” versus
“qid”. On the other hand, check boxes and pull-down or drop-down lists
carry their own set(s) of errors.66-68 Bar coding and computerized pharmacy
systems can also be implemented to decrease the occurrence of drug
errors.69-73 Most errors stem from “sensory” and “cognitive” overload by
multi-tasking personnel caring for many patients who may need critical
intervention at a moment’s notice. If the number of personnel on staff is
below optimum, the situation can be significantly worsened.
In the ICU, EMR errors can be minimized by careful checking and back-up
checking by another member of the staff. This is, of course, more difficult
under often urgent circumstances, but the potential consequences of
medication errors should not be ignored. Having a dedicated “partner” as
part of a plan to check the other’s calculations and actions, EMR entries can
provide greater safety and improved quality of care.73 Often, it is unclear or
unknown if a patient in the ICU is on any other medication from another
provider. Family members can be asked to bring in any medicines
(prescription, OTC and supplements) so that these can be examined. If the
patient is conscious and responsive, he or she can also be asked to go
through the list of home medications. This approach can minimize potential
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drug interactions and other ADEs.74-76 Drug interactions are associated with
longer times in the ICU and end-organ damage in addition to the ADEs.77-78
Drug interactions may depend on unique patient factors such as liver and
kidney function and altered protein binding. The interactions can be of a
pharmacokinetic or a pharmacodynamic nature resulting in altered
concentrations of the drug or its active or inactive metabolites
(pharmacokinetics) or may result in additive, synergistic or antagonistic
interactions (pharmacodynamic). Finally, what is clinically insignificant in a
non-critical patient may be highly significant for an ICU patient.79 One recent
study indicated that the most common medications involved in drug
interactions in an ICU setting were anti-platelet or anticoagulants, such as:80

aspirin/heparin/venlafaxine/duloxetine/warfarin

heparin/venlafaxine

heparin/duloxetine

warfarin/venlafaxine

antihypertensives (amiodarone/fentanyl)

antibiotics (azithromycin/sotalol; linezolid/metoclopramide

psychiatric medications (quetiapine/methylprednisolone;
venlafaxine/metoprolol)
Model For Improvement
The Institute for Healthcare Improvement follows a Model for Improvement
framework called the “Plan-Do-Study-Act” (PDSA) Model. This model follows
the cycles of PDSA with questions that can impact future PDSA cycles. The
PDSA questions might entail discussions of what is hoped to be accomplished
and how will that accomplishment be measured.
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The Institute for Healthcare Improvement has a step-by-step program that
can be found at its website. The model is intended to accelerate
improvement and to be incorporated within existing models healthcare
organizations may already have in place. The three questions can be
addressed in any order and the PDSA cycle tests the changes that have been
put in place.
Measurement is considered a critical part of the improvement process and
the IHI defines three types of measurements:

Outcome Measures
o “How does the system impact the values of patients, their health
and wellbeing? What are impacts on other stakeholders such as
payers, employees, or the community?”82
o In the ICU, an example of an outcome measure would be the
percent unadjusted mortality or Adverse Drug Events (ADE) per
1000 doses.

Process Measures
o “Are the parts/steps in the system performing as planned? Are
we on track in our efforts to improve the system?”82
o In the ICU, an example of a process measure would be the
number of patients seen intentionally and on schedule.

Balance measures which involve looking at various systems from
different perspectives.
o “Are changes designed to improve one part of the system
causing new problems in other parts of the system?”82
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o In the ICU, an example of a balance measure would be to ensure
that readmission rates are not increased by the changes
implemented.

The National Coordinating Council (NCC) for Medication Error
Reporting and Prevention (MERP) is a group of 27 independent
organizations with a goal of maximizing the safety of medications and
the increased awareness of potential medication errors using open
communication, increased reporting and the promotion of error
prevention strategies.

MEDMARX is a self-reporting and anonymous program that allows
hospitals to access and track medication errors. Intensive care unit
medication errors accounted for 6.6% of those reported, with 3.7% of
those considered harmful.83 The most common ICU errors were in the
administration phase of medication and most of those were the
omission of medications. Other medication errors that were more
common in the ICU setting were errors in dispensing devices and
calculation mistakes. These errors were nearly twice as likely to cause
harm and were reported to either the patients or their
family/caregivers less frequently than in non-ICU settings.
Communication with the individual who made the error was done only
about one-third of the time.83 In addition, no remedial action was
taken in more than half the cases reported. Interestingly, the authors
of a national study on medication errors in the ICU concluded that “the
characteristics of the ICU medication errors suggest that whatever
hypothetical advantages might be provided by the better staff-to40
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patient ratio, increased monitoring and specialized staff training in the
ICU are negated by the higher acuity and number of drugs per
patient.”83

Overall, the frequency of medication errors in the ICU has been
measured and has varied from 1.2 per 1000 patient days to 947 per
1000 patient days with a median of 105.9 per 1000 patient days.
While this wide range reflects differences in study design and
definitions of medication errors, most medication errors in the studies
were preventable ones.

Since ICU errors tend to have more serious consequences for patients,
it has been considered important to have ICU-specific approaches.
Surveillance methods can allow for environment-specific improvements
in the ICU.84 In addition, implementation of computerized physician
order entry (CPOE) is often recommended, though this is not without
its own associated sets of errors.85

EMRs are capable of detecting and predicting adverse drug reactions
(ADRs).86-90 The Veteran’s Administration (VA) has unified its ADR
reporting system, increasing the VA’s ability to monitor, track and
record ADRs throughout its hospital and clinic systems.89 However,
other studies have indicated that there are differences in accuracy and
comparability of records from various sources.
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Medication Administration Errors
Studies have indicated that approximately one-third of all ADEs are due to
medication administration errors.91, 92 Medication administration errors can
be due to the following; the most common reasons are listed first (in bold):

Incorrect dose

Incorrect rate

Incorrect drug

Incorrect time

Incorrect technique

Incorrect dose

Incorrect form

Incorrect patient

Incorrect route
The AHRQ has produced a chart of “High Alert Medications” and individual
drugs.
Drug Category
Individual Drugs

Antiretroviral agents
 Carbamazepine

Chemotherapy, oral
 Chloral hydrate liquid

Hypoglycemic agents, oral

Immunosuppressant agents

Insulin

Opioids, all formulations

Pregnancy category X drugs

Pediatric liquid medications that
require measurement
o
Sedation of children
 Heparin
o
Unfractionated/low-molecular
weight
 Methotrexate
o
Non-oncologic use
 Midazolam liquid
o
Sedation of children
 Propylthiouracil
 Warfarin
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The AHRQ also produced a “Fault Tree Risk Model.” The types of errors listed
in the Fault Tree model include:93

Unfamiliar task performed at speed/no idea of consequences

Task involving high stress levels

Complex task requiring high comprehension and skill

Select ambiguously labeled control/package

Failure to perform a check correctly

Error in routine operation when care required

Well designed, familiar task under ideal conditions

Human performance limit
Stress, lack of time, urgency, task complexity, look-alike drug names and/or
packages and unclear prescriptions (either because of unclear handwriting or
unclear specifications) all impacted on the medication administration errors.
The AHRQ has a number of safety strategies recommended to prevent ADEs
in general and specifically administration errors.
Strategies to prevent adverse d
STAGE
Prescribing
SAFETY STRATEGY

Avoid unnecessary medications by adhering to conservative
prescribing principles

Computerized provider order entry, especially when paired
with clinical decision support systems
Transcribing

Medication reconciliation at times of transitions in care

Computerized provider order entry to eliminate handwriting
errors
Dispensing

Clinical pharmacists to oversee medication dispensing
process

Use of "tall man" lettering and other strategies to minimize
confusion between look-alike, sound-alike medications
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Administration

Adherence to the "Five Rights" of medication safety
(administering the Right Medication, in the Right Dose, at
the Right Time, by the Right Route, to the Right Patient)

Barcode medication administration to ensure medications
are given to the correct patient

Minimize interruptions to allow nurses to administer
medications safely

Smart infusion pumps for intravenous infusions

Patient education and revised medication labels to improve
patient comprehension of administration instructions

Principles of conservative prescribing:95
While most nursing staff cannot prescribe medications, and while some
of the following principles do not necessarily apply to the ICU, it can be
useful to understand the basics of the approach.
o Seek Nondrug Alternatives First
o Consider Potentially Treatable Underlying Causes of Problems
Rather Than Just Treating the Symptoms With a Drug

In the ICU, this principle can be translated as ensuring that
the symptom that is being treated truly corresponds to the
cause—in other words, is the diagnosis truly valid and have
alternative diagnoses been fully explored?
o Look for Opportunities for Prevention Rather Than Focusing on
Treating Symptoms or Advanced Disease

For patients on mechanical breathing devices, is the nursing
staff checking frequently for signs of pneumonia or
respiratory difficulty? Are post-surgical patients monitored
for blood loss? Could symptoms observed be due to unnoticed co-morbidities?
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o Use the Test of Time as a Diagnostic and Therapeutic Trial
Whenever Possible

This is not always possible or even prudent in the ICU setting,
but a corollary of this principle is to take time to review the
potential for diagnostic or medication errors.

Computerized provider order entry:73, 91-93, 96, 97
o Computerized provider order entry (CPOE) describes any system
where clinicians (or nurses, in a CNOE) enter medication orders,
tests and procedures into a computer system. The order is then
transmitted directly to the pharmacy, or the appropriate lab. “A
CPOE system, at a minimum, ensures standardized, legible, and
complete orders and thus has the potential to greatly reduce errors
at the ordering and transcribing stages.”98
o Clinical decision support systems (CDSS) are often paired with
CPOEs and are designed to improve clinical decision-making. A
CDSS is set up to respond to a trigger or a red flag based on the
diagnosis, specific lab results, medications ordered (or not ordered)
and combinations of these. The triggers may alert the user to
problems or inconsistencies in the orders given.
Throughout the
process, warnings or reminders may be given.
o Computerized Nurse order entry (CNOE), when implemented,
decreased medication administration errors particularly where there
was resistance to CPOE.97

Medication reconciliations:99, 100
o The greatest risk for medication administration errors occurred
when patients were being transitioned from one area of care to
another.
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o Pharmacist directed interventions were generally most successful in
reducing ADEs in high-risk patients such as those in the ICU.

The involvement of clinical pharmacists has been shown to decrease
the frequency of ADEs as well as other medication errors.101

"Tall man" lettering or the use of mixed case letters to maximize
awareness of similar-sounding drugs has been a strategy used to
reduce medication administration errors.
acetaZOLAMIDE
acetoHEXAMIDE
Bupropion
busPIRone
Clomiphene
clomipramine
CycloSERINE
cyclosporine
DAUNOrubicin
DOXOrubicin
vinBLAStine v
vincristine
ALPRAZolam
LORazepam
Prednisone
prednisolone
AVINza
INVanz
AzaCITIDine
azathioprine
CeFAZolin
cefoTEtan
cefOXitin
cefTAZidime
ceftriaxone
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The Five Rights of Medication Safety:
The Five Rights of Medication Safety

Administering the Right Medication

in the Right Dose,

at the Right Time,

by the Right Route,

to the Right Patient
 Bar Code Technology has proven effective at reducing medication
administration errors.102-104 It should be noted that a number of studies
have indicated that implementing such technology can cause “significant
changes in workflow were necessary to achieve these results and caution
that successful use of this technology requires considerable attention to
development and implementation.”105
 Interruptions in Nursing Activities:
o It is likely that every nurse in any activity has been frustrated from
time-to-time by interruptions. It is also likely that every nurse can
relate an experience where patient safety was negatively impacted by
that interruption, particularly during the administration of medications.
Most studies describing this situation, however, have been voluntary
reports, surveys or self-reported experiences. It is generally accepted
that interruptions have a negative impact on an actively multi-tasking
nursing staff.
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More recently, studies have more definitively indicated that
interruptions in medication administration can significantly impact
patient safely.106-111 Some of the proposals for improvement included
the use of a single patient medication sheet for recording of drug
prescription, preparation and administration as well as any incident
reporting.111 Another study recommended “professional groundedness”
to “retain a state of equilibrium in a field of unnecessary interruptions
and to prevent interruptions from occurring.”108 In another study, a
multi-intervention program was implemented that included:
1) A single room was for medication preparation;
2) A red tabard was worn by the nurse responsible112 for the
medication rounds. The tabard was meant to indicate “Please, do
not interrupt me, I am managing medications”
3) Education of hospital personnel on the dedicated medication
room and the meaning of the red tabard.

Rather paradoxically, the tabard was more effective with patients than
it was with staff and interruptions from staff increased to up to
40.5%.112

Smart infusion pumps can, in theory, reduce medication errors. They
cannot, however, eliminate errors where the wrong patient is
administered medication through the smart infusion pump or if the
wrong medication (or dosage) is given. It is felt that by integrating a
smart infusion pump along with bar-code technology, even more
errors can be avoided.113-115
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Communication Errors
Effective communication should be considered a core clinical skill. Clear and
effective communication between the patient and nursing staff and between
the family and nursing staff can educate patients and families on complex
information that directly impacts their health.
Clear and effective communication helps patients and families make
appropriate and well-informed choices; allows patients and families to be
aware of potential adverse effects and outcomes and how they compare to
potential therapeutic gains; and helps keep patients and families cooperative
with the chosen treatments.
An honest disclosure of an error, whether it is a diagnostic error or a
medication error can be difficult for all involved. However, research (and
ethics) indicates that this is the best approach. For the most part, the
benefits of disclosure outweigh the potential negative consequences.116
Effective Communication with the Patient and the Family
The following should be considered before, during and after communication
of medical errors with the patient and the patient’s family.
First:
Ensure that all the pertinent information is available and at hand for all
meetings
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Second:
Ensure that any and all meetings are held at a comfortable location, allowing
for privacy concerns. Only medical staff members who have responsibility for
the patient’s care should be present and only those that the patient, or
family, is or are aware will be present and who have received the patient’s
(or family’s) consent to be present.
In addition, a recent review of the literature has the following suggestions
regarding a meeting:116
During the meeting there should be a –

Clear description of the adverse event and probable outcome

Brief and accurate explanation of what happened

Expression of sorrow or regret and a genuine apology

Revision to the care plan, rehabilitation

Information about measures being taken to prevent a similar
occurrence, opportunity for further discussion

discussion of procedures for compensation

emotional support

details of a full inquiry
However, the best chance of improving patient safety and encouraging
effective communication is to involve the patient (and family) as much as
possible in the patient’s care. This is not always straightforward or even
possible with some ICU patients, but if the effort is made by the medical
staff to involve and inform the patient and family in as much of the patient’s
care as feasible, given the patient’s medical condition, it is believed that all
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will benefit. The American College of Critical Care Medicine117 has also
recommended “Patient Centered Care”
The AHRQ has published “20 Tips to Help Prevent Medical Errors”, a patient
fact sheet. Another patient fact sheet “Five Steps to Safer Health Care”
presents another approach to empowering the patient in his or her health
care. The Five Steps for patients to prevent medical errors are:
1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a
doctor you feel comfortable talking to. Take a relative or friend with
you to help you ask questions and understand the answers.
2. Keep and bring a list of ALL the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you
take, including non-prescription medicines. Tell them about any drug
allergies you have. Ask about side effects and what to avoid while
taking the medicine. Read the label when you get your medicine,
including all warnings. Make sure your medicine is what the doctor
ordered and know how to use it. Ask the pharmacist about your
medicine if it looks different than you expected.
3. Get the results of any test or procedure.
Ask when and how you will get the results of tests or procedures.
Don't assume the results are fine if you do not get them when
expected, whether in person, by phone, or by mail. Call your doctor
and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
Ask your doctor about which hospital has the best care and results for
your condition if you have more than one hospital to choose from. Be
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sure you understand the instructions you get about follow up care
when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly
what will be done during the operation. Ask your doctor, "Who will
manage my care when I am in the hospital?" Ask your surgeon:

Exactly what will you be doing?

About how long will it take?

What will happen after the surgery?

How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and nurses about any allergies, bad
reaction to anesthesia, and any medications you are taking.118
While the special circumstances of the ICU can preclude a patient from being
empowered, the medical and nursing staff can “step in” and “stand in” for
the patient.
Special Concerns for Communication with ICU Patients
Patients in the ICU may have complex communication needs and the nursing
staff is often pressed for time. There is growing understanding of the
benefits of effective communication skills.119-125
The Interdisciplinary Nursing Quality Research Initiative (INQRI) of the
Robert Wood Johnson Foundation funded the SPEACS-2 (Study of Patient52
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Nurse Effectiveness with Assisted Communication Strategies) project,
“Improving Patient Communication and Quality Outcomes in the ICU”
facilitating patient communication for critically ill patients. This is a selfdirected set of learning modules using augmentative and alternative
communication (AAC).126, 127
A recent study indicated that the nursing staff in ICUs consider that 2 main
themes are involved in their communication with patients and families.124
The first theme was one of a “translator” where the nursing staff were
essentially the mediators and translators in the communications between the
doctor and patient or the patient’s family and between the patient or the
patient’s family and the doctors, though for a variety of reasons, the
communication was often unidirectional. This role, however, often led to
feelings of frustration and constraint.124
The second theme was termed “Said versus Not Said” There were a number
of different aspects of this theme, which often reflected on the “translator”
theme:

Differences in opinion between the nurse and the clinician where the
nurse did not feel empowered to disclose the difference of opinion.

Conferring with other staff before discussing a specific event with the
patient or the patient’s family.

Deferring communication on specific issues (i.e., test results or the
implications of various therapies) that the nurse did not feel was part
of the nursing role.

Nurses often avoided communication with their patients or their
patients’ families if the communication would impact on domains
termed “domain of sharing power and responsibility” or the “domain of
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therapeutic alliances.”124 Many nurses believed that this was not part
of the nursing responsibility. Nursing supervisors and nurse
practitioners may be more involved at this level.
What To Do in the Event of a Mistake
Reporting errors, while sometimes difficult professionally, are essential to
improvement, as well as to the health and wellbeing of patients. In addition,
nurses—and all health care workers—have an ethical obligation to report
errors stemming from the principles of beneficence (doing good) and
nonmaleficence (preventing harm).128
Reporting may be voluntary or mandatory:
“Voluntary reports may encourage practitioners to report near misses and
errors, thus producing important information that might reduce future
errors.”128 Mandatory reporting is often under state laws, and every nurse
(and other healthcare professional) should make herself or himself aware of
her or his legal responsibilities. To give two examples, in Pennsylvania, the
Medical Care Availability and Reduction of Error (MCARE) Act of 2002 has an
online system of reporting. The New York Patient Occurrence Reporting and
Tracking System (NYPORTS), requires that the following incidents be
reported:
The following incidents shall be reported to the department:129
1. Patients' deaths in circumstances other than those related to the natural
course of illness, disease or proper treatment in accordance with
generally accepted medical standards;
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2. Injuries and impairments of bodily functions, in circumstances other
than those related to the natural course of illness, disease or proper
treatment in accordance with generally accepted medical standards that
necessitate additional or more complicated treatment regimens or that
result in a significant change in patient status;
3. Equipment malfunction or equipment user error during treatment or
diagnosis of a patient that results in death or serious injury of a patient;
4. Patient elopements resulting in death or serious injury;
5. Abduction of a patient of any age;
6. Sexual abuse/sexual assault on a patient or staff member within or on
the grounds of a general hospital;
7. Physical assault of a patient or staff member within or on the grounds of
a general hospital;
8. Discharge or release of a patient of any age, who is unable to make
decisions, to other than an authorized person;
9. Patient or staff death or serious injury associated with a burn incurred
from any source in the course of a patient care process;
10. Patient suicide, attempted suicide or self-harm resulting in serious
injury;
11. Poisoning occurring within the hospital;
12. Fires or other internal disasters in the hospital which disrupt the
provision of patient care services or cause harm to patients or staff
members;
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13. Disasters or other emergency situations external to the hospital
environment which affect hospital
operations; termination of any services
vital to the continued safe operation of
the hospital or to the health and safety of
its patients and staff members, including
but not limited to the termination of
telephone, electric, gas, fuel, water, heat,
air conditioning, rodent or pest control,
laundry services, food, or contract
services;
14. Strikes by staff members.
Under the section referring to patient injuries,
9 categories are covered in the NYPORTS
system:

Aspiration

Embolic

Burns

Falls

Intravascular catheter related

Laparoscopic

Medication errors

Perioperative/periprocedural

Procedure related
Distinction is made between an
adverse outcome that is primarily
related to the natural course of
the patient’s illness or underlying
condition (not reviewed under
the Sentinel Event Policy) and a
death or major permanent loss of
function that is associated with
the treatment (including
“recognized complications”) or
lack of treatment of that
condition, or otherwise not
clearly and primarily related to
the natural course of the
patient’s illness or underlying
condition (reviewable under the
Sentinel Event Policy). In
indeterminate cases, the event
will be presumed reviewable and
the critical access hospital’s
response will be reviewed under
the Sentinel Event Policy
according to the prescribed
procedures and time frames
without delay for additional
information such as autopsy
results.
Major permanent loss of function
means sensory, motor,
physiologic, or intellectual
impairment not present on
admission requiring continued
treatment or lifestyle change.
When major permanent loss of
function cannot be immediately
determined, applicability of the
policy is not established until
either the patient is discharged
with continued major loss of
function or two weeks have
elapsed with
persistent major loss of function,
whichever is the longer
period.”127
Sentinel events are defined by the Joint Commission as “an unexpected
occurrence involving death or serious physical or psychological injury, or the
risk thereof. Serious injury specifically includes loss of limb or function. The
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phrase, "or the risk thereof" includes any process variation for which a
recurrence would carry a significant chance of a serious adverse
outcome. Such events are called "sentinel" because they signal the need for
immediate investigation and response.”130 Sentinel events may be
voluntarily reported to the Joint Commission.
In critical access hospitals, the Joint Commission may review a sentinel
event. Not every occurrence applies to every critical access hospital, but the
following is a list of sentinel events that may trigger a review:131

The event has resulted in an unanticipated death or major permanent
loss of function not related to the natural course of the patient’s illness
or underlying condition.
Or

The event is one of the following (even if the outcome was not death
or major permanent loss of function not related to the natural course
of the patient’s illness or underlying condition):
o Suicide of any patient receiving care, treatment, and services in
a staffed around-the-clock care setting or within 72 hours of
discharge
o Unanticipated death of a full-term infant
o Abduction of any patient receiving care, treatment, and services
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o Discharge of an infant to the
wrong family
o Rape, assault (leading to death
or permanent loss of function), or
homicide of any patient receiving
care, treatment, and services
o Rape, assault (leading to death
or permanent loss of function), or
homicide of a staff member,
licensed independent practitioner,
visitor, or vendor while on site at
the health care organization.

Hemolytic transfusion reaction
involving administration of blood or
blood products having major blood
group incompatibilities (ABO, Rh, other
blood groups)

Invasive procedures, including surgery,
on the wrong patient, wrong site,
“Sexual abuse/assault (including
rape), as a reviewable sentinel
event, is defined as unconsented
sexual contact involving a patient
and another patient, staff
member, or other perpetrator
while being treated or on the
premises of the critical access
hospital, including oral, vaginal,
or anal penetration or fondling of
the patient’s sex organ(s) by
another individual’s hand, sex
organ, or object. One or more of
the following must be present to
determine reviewability:

Any staff-witnessed
sexual contact as
described above

Sufficient clinical
evidence obtained by the
hospital to support
allegations of
unconsented sexual
contact

Admission by the
perpetrator that sexual
contact, as described
above, occurred on the
premises”
“All events of invasive procedure,
including surgery, on the wrong
patient, wrong site, or wrong
procedure are reviewable under
the policy, regardless of the
magnitude of the procedure or
the outcome.”127
wrong procedure

Unintended retention of a foreign object in a patient after surgery or
other invasive procedures

Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)

Prolonged fluoroscopy with cumulative dose >1,500 rads to a single
field or any delivery of radiotherapy to the wrong body region or
>25% above the planned radiotherapy dose
Medication errors can be reported at the Institute for Safe Medication
Practices (www.ismp.org or by calling 1-800-FAIL-SAF (E). Individual
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institutions may also have specific reporting requirements. It is the
responsibility of each member of the nursing staff to familiarize themselves
with these specific legal, ethical and professional requirements.
Summary
It is well recognized that nursing staffs in the ICU must be constantly alert
and aware of all their patients and their patient’s needs. It is also well
recognized that this can be difficult and stressful. The reduction of
preventable mistakes in the ICU can benefit all, however. There are obvious
benefits to the patient, but there are benefits for the nursing and medical
staff as well. These benefits include a greater sense of accomplishment,
boosted morale and a greater sense of professionalism. The emphasis on
increased patient safety will increase, particularly because of the legal,
health and economic benefits engendered.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1.
Which of the following would allow one to distinguish between a
STEMI and a NSTEMI
a. Troponin values increase in a STEMI but not in an NSTEMI
b. EKG readings would show an ST elevation in a STEMI but not in
an NSTEMI
c. STEMIs tend to radiate to the left side in men and to the right
side in women
d. Creatine Kinase levels increase to a much greater extent in
STEMI vs. NSTEMI
2.
A trauma patient with extensive bleeding is admitted to your
ICU. Which of the following pre-existing conditions would be
MOST important to be aware of.
a. A history of coagulopathies
b. A history of immune suppression
c. A history of drug abuse
d. A history of autoimmune diseases
3.
Which of the following correctly lists symptoms of a pulmonary
embolism
a. A sudden drop in blood pressure
b. A sudden rise in blood pressure
c. Tachycardia, dyspnea, coughing
d. Fever, lumbar back pain and shortness of breath
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4.
You have a number of patients in the ICU. Which of the
following conditions would likely put them at greatest risk of
aspergillosis?
a. Thrombocytopenia
b. Mechanical ventilation
c. Hypothyroidism
d. Sedation with a lowered respiratory rate
5.
Which of the following has been reliably used to reduce
medication errors by highlighting similarities between the
names of medications
a. Computerized pharmacy systems
b. Calling the ordering physician to re-write the order
c. Asking the patient if this is the medication they are taking at
home
d. Use of tall man lettering
6.
Your patient is experiencing RLQ pain. Of the following, based
on the location of the pain, which diagnosis is the MOST likely?
a. Hepatic abscess
b. Gallstone
c. Kidney stones
d. Appendicitis
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7.
Which of the following represents the greatest risk for
pneumonia?
a. A history of abdominal surgery
b. Endotracheal intubation with mechanical ventilation
c. Age under 65
d. Male gender
8.
Which of the following symptoms may be confused with a heart
attack?
a. Aspergillosis
b. Pulmonary embolism
c. Ectopic pregnancy
d. Sepsis
9.
In an elderly patient, which of the following is often the first
sign of a pulmonary embolism?
a. Altered mental status
b. Pain
c. Fever
d. Anxiety
10. According to the Joint Commission, sentinel events:
a. Signal the need for immediate investigation and response
b. Require mandatory reporting
c. Are always investigated at every hospital
d. Are all unexpected occurrence involving death or serious physical
or psychological injury
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Correct Answers:
1.
b
6.
d
2.
a
7.
b
3.
c
8.
b
4.
a
9.
a
5.
d
10. d
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
Kohn, L., J. Corrigan, and M. Donaldson, To Err is Human: Building a
Safer Health System. , ed. Institute of Medicine. 1999, Washington,
DC: National Academy Press.
2.
Sibbald, M. and R.B. Cavalcanti, The biasing effect of clinical history on
physical examination diagnostic accuracy. Medical Education, 2011.
45(8): p. 827-834.
3.
Norman, G., Dual processing and diagnostic errors. . Adv Health Sci
Educ Theory Pract, 2009. 14: p. 37–49.
4.
Ohar, J., L. Fromer, and J.F. Donohue, Reconsidering sex-based
stereotypes of COPD. Primary Care Respiratory Journal: Journal Of The
General Practice Airways Group, 2011. 20(4): p. 370-378.
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5.
Winters, B., et al., Diagnostic errors in the intensive care unit: a
systematic review of autopsy studies. BMJQS, 2013. 22(10): p. 789792.
6.
Fein, A.M., Pneumonia in the elderly: overview of diagnostic and
therapeutic approaches. Clinical Infectious Diseases: An Official
Publication Of The Infectious Diseases Society Of America, 1999.
28(4): p. 726-729.
7.
Hotchkiss, J.R. and P.M. Palevsky, Care of the critically ill patient with
advanced chronic kidney disease or end-stage renal disease. Current
Opinion in Critical Care, 2012. 18(6): p. 599-606.
8.
Khan, D.A., Treating patients with multiple drug allergies. Annals of
Allergy, Asthma & Immunology, 2013. 110(1): p. 2-6.
9.
Dioun, A.F., Management of multiple drug allergies in children. Current
Allergy And Asthma Reports, 2012. 12(1): p. 79-84.
10.
Dewachter, P., et al., Anesthesia in the patient with multiple drug
allergies: are all allergies the same? Current Opinion in
Anesthesiology, 2011. 24(3): p. 320-325.
11.
Chen, C.J., et al., A comprehensive 4-year survey of adverse drug
reactions using a network-based hospital system. Journal of Clinical
Pharmacy & Therapeutics, 2012. 37(6): p. 647-651.
12.
Graber, M.L., The incidence of diagnostic error in medicine. BMJ
Quality & Safety, 2013. 22 Suppl 2: p. ii21-ii27.
13.
Schiff, G.D., et al., Diagnostic error in medicine: analysis of 583
physician-reported errors. Archives Of Internal Medicine, 2009.
169(20): p. 1881-1887.
14.
Berner, E.S., Diagnostic error in medicine: introduction. Advances in
Health Sciences Education, 2009. 14(Suppl 1): p. 1-5.
15.
Braunwald, E., E. Antman, and J. Beasley, ACC/AHA Guidelines for the
management of patients with unstable angina and non-ST segment
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elevation myocardial infarction: A report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on the management of patients with unstable
angina). Journal of American College of Cardiology, 2000. 36: p. 970–
1062.
16.
Hamm, C., Braunwald, E., APACHE II: A classification of unstable
angina revisited. Circulation 2000. 102: p. 118-122.
17.
Nassar Junior, A.P., et al., SAPS 3, APACHE IV or GRACE: which score
to choose for acute coronary syndrome patients in intensive care
units? São Paulo Medical Journal = Revista Paulista De Medicina, 2013.
131(3): p. 173-178.
18.
Segal, J.B., et al., Review of the evidence on diagnosis of deep venous
thrombosis and pulmonary embolism. Annals Of Family Medicine,
2007. 5(1): p. 63-73.
19.
Ramzi, D.W. and K.V. Leeper, DVT and pulmonary embolism: Part I.
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